Socialization in professional reality integration for nursing student transition (SPRINT) to improve professional competence: A quasi-experimental study

Abstract

Background

Professional socialization could support competency achievement and assist the transition phase. It is rare to find quantitative studies examining the effects of professional socialization for nursing students (NS).

Objectives

To investigate the effects of a socialization in professional reality integration for nursing student transition (SPRINT) to improve the professional competence of undergraduate NS in Indonesia.

Design

A quasi-experimental study non-equivalent control group pre-test post-test design was conducted using convenience sampling.

Participants

One hundred twenty NS (60 participants in the experimental group and 60 participants in the control group) from two nursing departments in private universities in Indonesia.

Methods

The SPRINT educational intervention consisted of professional socialization training using several learning methods and activities. Meanwhile, the control group received conventional socialization. The Nurse Professional Competence short-form (NPC-SF) scale was evaluated prior to the participants’ internship program, lasting from 6 to 12 weeks after clinical education in both groups.

Results

SPRINT intervention significantly increased overall professional competence scores of the experimental groups higher than the control group. By comparing the mean scores in three times measurement, the six competency areas mean score increased significantly for the experimental group while, for the control only three areas of competence increased in twelve week post-test.

Conclusion

A “SPRINT” as an innovative educational program developed in collaboration with academia, clinical preceptors, could improve professional competence. It is recommended to implement SPRINT program to assist the smooth transition from academic into clinical education.

1. Introduction

Globally, nurses are a critical part of healthcare services; however, newly graduated nurses (NGN) choose to leave their job due to their misperception of nursing [1]. Turnover of NGN has reached rates of 8.8%–37%, (depending on the state [2] which is often the result of a stressful transition in the first year of practice as well as a lack of socialization into the roles of the nursing profession [2]. In addition, a lack of professional competence significantly increases patient mortality and morbidity in hospitals [3,4]. Professional competence is the main goal of nursing education to assure patient safety and quality of care [4].

There is an urgent need for the preparation of well-qualified nurses equipped to understand future challenges and the application of innovative teaching strategies to improve the retention of NGN [5]. Furthermore, innovative teaching-learning strategies are required to support students’ professional socialization that emphasize active participation and collaboration between faculty and students [6,7]. Thus, it is necessary to improve competency and assist students in transitioning by providing professional socialization [8].

2. Background

Undergraduate nursing education supposedly enhances new graduates’ readiness to achieve the entry-level competencies in clinical practice [9]. However, NGNs often do not meet the expectation of professional competence, including skills, knowledge, and clinical judgment [10]. Achieving professional competence is vital for students to provide safe, excellent nursing care [11]. Although NGNs may be willing to learn in clinical practice, they often experience inadequacy when developing professional competence, in Swedia [12]. Furthermore, NGNs were reported to lack competency in soft skills, as well as other critical requirements of the nursing profession such as communication skills, critical thinking, providing a helping role, teamwork and professionalism [13]. Despite the literature revealing numerous interventions to ease the transition to become a professional nurse which enhances job satisfaction and retention [2], the problem of transition and integration still exists. Several studies have revealed that students experience transition shock that result in feelings of incompetence, stress, anxiety [2], the dissonance between hope and experience in practice [14], and even on one occasion an incident of incivility during professional socialization in clinical placement [15].

Providing professional socialization and applying innovative learning strategies to students have several benefits. Such benefits for students include personal and professional development [8,16], a sense of belonging, personal resilience, motivation to pursue a nursing career and the acquisition of soft skills [15,17]. Despite its acknowledged benefits, many NS continue to receive inadequate professional socialization during the transition phase leading to a reality shock [18]. This situation could hinder achieving competency and frustrate a future nursing career. The last year of the nursing program is the greatest transition where professional identity is developed by gaining satisfaction and committing to professional practice [19]. The other benefit of successful professional socialization is that it enables students to become competent, have a strong professional identity and behave professionally [8,20]. Moreover, professional socialization effectively improves clinical competencies and personal qualities of the undergraduate NS [8,16].

The undergraduate nursing program in Indonesia consists of two stages, including an academic stage of eight semesters and a professional stage of two semesters [21]. In Indonesia, passing the National Nursing Competency Examination (NNCE) is required for eligibility for a nursing license, according to the Ministry of Health Education [22]. However, the pass rate of NNCE is regarded as low and has not achieved desired outcomes [22,23]. The nursing graduates who passed only increased slightly from 57.10% in 2018 to 58.60% in 2019 [22]. Educational intervention peer learning could improve professional competence for Indonesian undergraduate NS. However, the sample size of previous study was relatively small and only involved one university [24].

Professional integration and socialization are essential to accepting, nurturing, and enculturing NS in the nursing profession, providing many benefits, such as enhanced satisfaction, self-efficacy, encouragement, dedication, perseverance and retention [5]. Despite the fact that students cannot control what happens in clinical practice, they can become actively involved in achieving adequate professional socialization [20]. In addition, nurse educators should facilitate a professional socialization program to assist students comprehensively so they can adapt into the nursing profession's culture prior to their clinical education [25]. Currently in Indonesia, however, there is no new application theory or any specific educational intervention related to professional socialization among undergraduate NS to assist the transition. Thus, it is deemed necessary to facilitate a smooth transition for students to enhance resilience to cope with adversity through professional socialization [15]. Professional socialization can also affect students' professional development and competency [16,26]. Then, improving nursing competencies necessitates the use of novel teaching and learning methods in nursing education [7].

To the researcher's knowledge, there has not yet been any study that has investigated the effect of professional socialization intervention on professional competence in undergraduate nursing education. Regarding this, the current study has developed the educational intervention which is connected to professional socialization among undergraduate Indonesian NS. This leads them to be accepted, nurtured, and encultured by the nursing profession. The Socialization in Professional Reality Integration for Nursing Student Transition (SPRINT) intervention program was based on the professional metamorphosis theory for undergraduate NS and the concept of professional socialization in nursing as a research framework [16,27]. It is also guided by professional socialization for nursing students [28]. Previous study found the effectiveness of professional socialization intervention in the transition and integration phase is three months [29]. The SPRINT program was developed by previous studies [28,30]. To achieve the learning outcomes of SPRINT, Gagne's Modified Nine-Step of Instruction [31] and Bloom's Revised Taxonomy for cognitive domain learning, such as remembering, understanding, applying, analyzing, evaluating, and creating [32] were used as a guide. Meanwhile, the nine-step process of Gagne's instructional design was used as a pedagogical framework of training, including (a) gain attention; (b) inform learners of the goals; (c) stimulate recall of prior learning; (d) present the content; (e) provide learning guidance; (f) elicit performance; (g) provide feedback; (h) assess outcomes; and (i) enhance retention and transfer to the job [33]. This paper should be of interest to readers in nursing education and practice. Thus, this study developed, introduced and implemented SPRINT as an innovative educational program for Indonesian undergraduate nursing students. It also aimed to examine the effect of SPRINT on professional competence in six specific areas.

3. Methods

3.1. Design and setting

A quasi-experimental study with non-equivalent control group pre-test post-test design was used in this study. Data collection for both groups was carried out in two nursing departments and teaching hospitals in Yogyakarta Special Province and Central Java, Indonesia. The professional nursing course was taught during the academic stage (theoretical phase) in both universities, and they used the formal nursing curricula from the Association Indonesian Nurse Education Center. Two private universities had similar characteristics including their professional values, professional culture, and teaching/learning methods. SPRINT was implemented into an experimental group as an innovative program to assist their adaptation and improve their professional competence.

3.2. Population and sample

The population of this study included fifth-year nursing students who were, at the time, undertaking internship at the selected teaching hospitals. The criteria for inclusion consisted of female or male nursing students who had finished the academic stage of the undergraduate nursing program, who were undertaking internship in clinical education in one of the teaching hospitals, who had a smartphone, and who could communicate well in Indonesian language. Nursing students who were undertaking internship in a community or psychiatric hospital were excluded from the study. Convenience sampling was used for nursing students who were available at the time of recruitment, met the inclusion criteria, and agreed to participate in this study. The formula for the sample size for intervention was based on [34] as follows:

$$\mathrm{S}\mathrm{a}\mathrm{m}\mathrm{p}\mathrm{l}\mathrm{e}\mathrm{s}\mathrm{i}\mathrm{z}\mathrm{e}=\frac{{2(\mathrm{S}\mathrm{D})2\times (\mathrm{Z}\alpha /2+\mathrm{Z}\beta )}^2}{{\mathrm{D}}^2}$$

• SD = Standard Deviation = from previous study (Gardulf et al., 2016)

• Zα/2 = 1.96 from Z-table at Type 1 error of 5%

• Zβ = 0.84 from Z-table at 80% power

• D = effect size = difference between mean values

$$\mathrm{S}\mathrm{a}\mathrm{m}\mathrm{p}\mathrm{l}\mathrm{e}\mathrm{s}\mathrm{i}\mathrm{z}\mathrm{e}=2(\mathrm{S}\mathrm{D}){}^2\mathrm{x}{(\mathrm{Z}\alpha /2+\mathrm{Z}\beta )}^2/D^2$$

• = 2 (11.3) ² x (1.96 + 0.84)²/6²

• 36= 255.4 × 7.84/

• = 55,61 ≈ 56

To address the dropout rate, an additional 20% was added into the calculation [35]. The researcher concluded that, by using the largest sample size, this would be a quasi-experimental study with a non-equivalent control group pre-test post-test design. As a result, the sample size for the experimental study was 71 and 72 for the control group.

To avoid the cross-contamination between the two groups, the researchers used students from two different universities and from two different years as our participants. The selection began with the control group, which included those who had undertaken their professional education in September 2018, met the recruitment criteria and agreed to participate in the study. Furthermore, in August 2019, students from other nursing schools that met the recruitment criteria and agreed to participate in the study were selected for the experimental group. Both the groups were tracked for three months included pre-clinical education and post-clinical education. From September 2018 to October 2019, 143 nursing students on two nursing programs were recruited, agreeing to participate in either the control (n = 72) or experimental group (n = 71). At the end of 12 weeks, 60 participants remained in the control group and 60 in the experimental group. Dropout occurred due to difficult to manage time in internship, not attending the classroom meeting and not filling in the questionnaire completely: 12 in the control and 11 in the experimental group.

Moreover, the Consort flow diagram was used in this study (Fig. 1). High retention rates for the experimental and control groups were achieved, at 84.50% and 83.33% respectively. These rates of ≥80% ensured power and internal validity in the longitudinal study [36].

Fig. 1.

Consort flow diagram.

3.3. Measurement

In this study, each respondent filled in a personal information form that was developed by the researchers, including five questions about the sociodemographic characteristics of the students: age, gender, the grade point of average (GPA), marital status, and ethnicity. Furthermore, the Nurse Professional Competence short-form (NPC-SF) developed by Nilsson et al. [37] in Sweden was adapted into an Indonesian version after obtaining the author's permission. The 35-item scale consisted of six competence areas: nursing care (NC); value-based nursing care (VBNC); medical and technical care (MTC); care pedagogics (CP); documentation and administration nursing care (DANC); and development of leadership organization nursing care (DLONC). The scale used a four-point Likert scale, ranging from 1 = to a very low degree to 4 = to a very high degree. The NPC-SF total scores varied between 32 and 128 with high scores indicating a high level of competence. Cronbach's alpha of the scale of the six competence areas ranged from 0.71 to 0.86 [37]. Multiple studies revealed that the internal consistency of the NPC-SF was high across all competence areas with the α values ranging 0.79–0.87 (Forsman et al., 2020), as well as the Cronbach's alpha for the competence areas ranging from 0.83 to 0.89 and the total scale was 0.96 [4]. In this study, the Cronbach alpha ranged from 0.77 to 0.86.

The researchers followed the five steps of WHO guidelines for translation and adaptation to achieve equivalence between original and translated versions, including forward translation, expert panel review, backward translation, pre-testing and cognitive interview, and final version [38]. The original instrument was translated by the researchers into “Bahasa Indonesia”, while two bilingual nursing professionals conducted back-translation of the Indonesian version back into English. The original and back-translated versions were used to compare accuracy. The final version was tested for validity and reliability through pre-testing and cognitive interviews with 30 BSN students unconnected with the study. Lastly, the final version of translated instruments was distributed to six experts in nursing to conduct an extensive panel expert review on the items and calculate the content validity index (CVI). Every expert carried out an independent content validity assessment by rating the content relevance of each item with a 4-point ordinal scale; 1 = not relevant, 2 = somewhat relevant; 3 = relevant; and 4 = highly relevant [39,40]. It was decided that the tool would have an excellent content validity by deleting three items, namely “administer prescription independently” in the MTC competence; “teach, supervise and assess students” in the DLONC competence; and “supervise and training co-workers/staff”, also in the MTC competence. The experts considered the BSN students competencies and practical in the Indonesian context. Thus, 32 items of the NPC short-form were used in this study.

3.4. Ethical considerations and data collection

Before beginning this study, approval was granted by the Institutional Review Board, the Indonesian Ministry of Home Affairs, two private universities and teaching hospitals. The researchers explained the aim of the study to the participants, who then gave both verbal and written consent. The data were collected from both groups at three time occasions: prior to enter the clinical education and then at six weeks in clinical education and twelve weeks after finished their clinical education. The data collection methods included a direct filling process in the questionnaire and by using a Google form when students practiced in different teaching hospitals. The participants were asked to spend 10–15 min to complete the questionnaires themselves. In this study, the respondents filled out the questionnaire in three times measurement, including a pre-test prior to clinical education, and then at 6 weeks and 12 weeks post-test. All participants’ contact details were obtained for further appointment. For follow-up purposes, four groups were created on WhatsApp. The researcher subsequently communicated with each group to set a proper date and time for the pre-test.

3.5. SPRINT educational program

The experimental group received SPRINT training consisting of a twelve-week session with approximately 2 h per week that were held pre-clinical education, clinical education and after professional clinical practice. The SPRINT intervention was conducted by the first researcher who had experience and had received training in soft skills. For the experimental group, participants attended soft skills training to orient them to the SPRINT program. Soft skills training for NS is considered important in the development of professionalism, self-confidence, coordination, friendliness and a successful career in nursing [41]. Soft skills are the key to life-long learning and are directly related to the core competencies that effectively deal with the demands and challenges of daily life [42]. Undergraduate nursing education should develop competency in soft skills to ensure the graduates are marketable and have high personal qualities [13,43].

In this study, SPRINT training was held in a classroom and was designed to stimulate prior knowledge and the students' practice skills to professional socialization. The training process used several learning methods and activities to improve students’ competencies, such as video simulation, discussion, self-directed learning, peer learning, and experiential learning. The researcher used interactive lectures with Powerpoint presentation and case studies showing the lack of socialization and competency that triggered discussion on the topic. Furthermore, in clinical education, preceptorships also were used as a learning tool.

Modules of SPRINT were also distributed to students in the experimental group after completing the educational session and after the post-test for the control group. The modules assisted the students in their transition from the academic stage to their professional clinical education. Furthermore, text messages were sent via WhatsApp containing tips on how to prevent stresss and adapt in the clinical environment and to provide words of encouragement. Two to three messages were sent each week to remind the respondents about the educational materials and remind them to write their weekly reflection. Furthermore, answers were provided to any questions about professional socialization and to increase competency through text messaging three days a week during intervention. The researcher also noticed the highly interactive level of chat in WhatsApp during this period. The SPRINT program and protocol of SPRINT training are illustrated in Table 1, Table 2, Table 3.

Table 1.

Educational intervention SPRINT and learning activities.

Program	Session	Time	Content	Strategies
Pre-clinical education	Week 1:	2 h	• Visualize the transformation from nursing student to professional nurse	• Video
	• Training SPRINT		• Learn the strategies to transition from academic into clinical practice	• Simulation
	• Reflection		• How to acquire the values, belief, norms, attitudes, knowledge, hard skills and soft skills in professional roles	• Discussion
				• Peer learning
				• Experiential learning
	Week 2–3: • Interaction via social	2 h/week	• Learn the knowledge and skills in professional role • Self-identification: strengths and weaknesses	• Self-directed learning • Experiential learning
	media • Reflection
Clinical education	Week 4–11	2 h/week	• Learn the skills, knowledge of clinical nursing	• Self-directed learning
	• Skill acquisition		• Provide basic nursing care	• Peer learning
	• Clinical mentoring		• Identify significant points of own experience in clinical education	• Experiential learning
	• Reflection			• Preceptorship
Post- clinical education	Week 12:	2 h	• Critical reflection about professional competency development	• Self-directed learning
	• Critical reflection			• Experiential learning

Table 2.

Protocol of SPRINT training.

Training Protocol of SPRINT with Modification Gagne's Nine Steps of Instruction			Methods	Bloom Taxonomy Revision
+	Prior day for training	Prepare nursing students and explore their expectation.	• Case studies related professionalism in nursing with reflection question.	Analyse and reflect on nursing professionalism and ethic.
1.	Getting attention from nursing students.	Introduce the importance of learning stimulus.	• Video: the professionalism transformation from student to PN	Improve the understanding and urgency of professional development for nursing students.
			• Group discussion using standard professional practice in nursing.
2.	Informing students of the learning objectives.	Clarify what students will get join the SPRINT training.	• Define and explain the objectives, benefits, mechanisms and strategies of SPRINT.	Ensure the understanding of the training goals.
			• Highlight the importance to have high professional competence to assure patient safety and quality of care
3.	Stimulating recall of prior learning.	Connect the content to the objectives to acquire experience from prior clinical practice.	• Know the effect of poor socialization on professional competence.	Facilitate recall with similar situations in clinical practice and establish relationship between causes and consequences.
			• Discuss prior experience in clinical practice and situations that focus on socialization that influence own their competence (experiential learning)
4.	Displaying content.	Provide good content and unity in structure of training.	• Discuss case scenario with group (peer learning)	Give opportunity to describe, explain, analyse and evaluate the case.
5.	Providing learning guidance.	Provide clear instruction and support for students to improve their active learning.	• Develop discussion & set up simulation based on prior experience. • Describe and analyse problems and look for solutions. • Provide feedback on student performance.	Apply their skill: create scenarios related to socialization in clinical practice that challenge students. ➢ Performance evaluation in hardskill and softskill
6.	Providing practice.	Provide opportunity to practice professional competence to confirm their understanding.
7.	Giving feedback.	Provide group and individual feedback for students to improve their performance and facilitate learning methods.
8.	Enhancing retention and transfer into practice.	Provide the strategies to support changes of competencies in future practice.	Develop support system & active learning methods, especially self-directed learning, peer learning, experiential learning and support from preceptor (preceptorship) in clinical practice.	Apply learning methods to professional clinical practice.
9.	Assessing learning outcomes.	Evaluate the training and the achievement of learning objectives.	Provide the chance for students to ask questions and clarify issues related to professionalism.	Evaluate the learning outcomes and training goals.

Table 3.

Protocol of SPRINT program.

Program and time	Facilitator's activities	Student's activities
Pre-clinical education Week 1–3	Prepare and deliver questionnaire NPC-SF for pre-test	Read and filled in the questionnaire to pre-test
	Sent the case studies a day before training related professionalism in nursing.	Read and analyse, based on the assignment.
	Facilitate training and introduce nursing professionalism in classroom.	Attend classroom session and pay attention to the training information.
	Assess students' readiness, feelings, expectations, strengths and weaknesses.	Provide personal ID; actively engage in information exchange on preparation, feelings, hopes and expectations.
	Give module SPRINT for nursing students & explain the learning activities.	Learn the module of SPRINT and remember to write weekly written reflection.
	Describe the importance of professional socialization and professional competence in the nursing profession.	Attend and pay attention.
	Deliver student behavioural contract.	Read, understand and sign contract.
	Send complete module (including philosophy of nursing, competencies, vision and mission of nursing institution, professional values, organizational culture, strategies of SPRINT) through WhatsApp group to every teaching hospital.	Learn the complete module & actively engage via WhatsApp
Clinical education Week 4–11	Provide support and motivation in the beginning of clinical practice.	Learn and improve readiness to enter clinical practice.
	Accompany nursing students to orientation on practical site with clinical preceptors and ward nurses.	Adaptation & building relationship with others in new clinical learning environment.
	Remind students to be active and cooperative in achieving the learning outcomes as well as to understand the importance to achieve professional competence	Get involved in SPRINT actively and cooperate with peers and instructors to achieve learning outcomes.
	Prepare and deliver questionnaire for post-test in six weeks through google form.	Read and filled in the google form to post-test six weeks.
	Teach student clinical skills and guide students in teaching/learning process, including knowledge, skills, attitude, behaviour, norms, values and roles of a professional nurse.	Develop new knowledge, skills, attitude, behaviour, norms, values and professional roles.
Post clinical education Week 12	Evaluate the professional competence of nursing students both hard skills and soft skills.	Nursing students write their critical reflection and evaluate their learning achievements following the SPRINT related to professional competence development
	Prepare and deliver questionnaire for post-test in twelve weeks directly.	Read and filled in the google form to post-test twelve weeks.

3.6. Control group

The control group received the conventional socialization information included in the orientation and preceptorship at the university and the selected teaching hospitals. General messages about socialization and answers to any inquiry from participants were provided three days a week for three months. However, no discussion was initiated or any question answered about transition and integration in the control group.

3.7. Data analysis

The data were analyzed using SPSS™ 22 version (IBM Inc., Chicago, IL, USA). Descriptive statistics, such as percentage, mean and standard deviation were used to analyse the demographic characteristics. The Kolmogorov Smirnov was used to check the normality data distribution, and the Chi-square test was used to compare the descriptive features between two groups. The paired sample t-test was used to compare the mean scores intragroup (pre- and post-test) and the independent t-test was used to compare the mean scores of the scales between the intergroup. The Repeated Measures ANOVA and Bonferroni post-hoc analysis were used to compare the mean scores of the scales in-group as well as to examine the effect of time and group. The level of significance was determined to be at p < 0.05.

4. Results

4.1. Descriptive characteristics of participants

The final sample size of the current study was 120 participants (60 participants in the control and 60 in the experimental group). Demographic characteristics of the Bachelor NS in the two groups are summarized in Table 4. The mean age of the respondents in the experimental group was 22.03 ± 0.86 and 22.25 ± 0.81 for the control group (Table 4). There were no significant differences in demographic variables between the two groups, such as gender, age, grade point average, marital status and ethnicity (p > 0.05). The two groups were composed primarily of female students (experimental = 76.7%, control = 86.7%).

Table 4.

Demographic characteristic and differences between the two groups (n = 120).

Demographic characteristics	Experimental (n = 60)	Control (n = 60)	Chi Square Test
	n (%)	n (%)	χ2	p value
Gender
Female	46 (76.7)	52 (86.7)	2.004	0.157
Male	14 (23.3)	8 (13.3)
Age
Mean age	22.03 ± 0.86	22.25 ± 0.81
<23 years	48 (80.0)	44 (73.3)	0.745	0.388
≥23 years	12 (20.0)	16 (26.7)
GPA			0.342	0.559
<3.00	1 (1.7)	2 (3.3)
≥3.00	59 (98.3)	58 (96.7)
Marital Status
Single	58 (96.7)	59 (98.3)	0.342	0.559
Married	2 (3.3)	1 (1.7)
Ethnicity
Javanese	51 (85)	55 (91.7)	1.294	0.255
Non Javanese	9 (15)	5 (8.3)

GPA: Grade Point Average; Chi square test, Significant at p < 0.05.

4.2. Effect educational intervention on improving professional competence

Table 5 compare the difference between the total PC scores of the pre-test and post-test in the experimental group examined by paired t-test. It was significant (t = −8.716, p = 0.00), indicating the participants in the SPRINT group demonstrated a significant impovement in professional competence, including the six competence areas after the educational intevention. The mean difference of professional competence from pre-test to twelve weeks post-test was 11.6 for the experimental group and 4.91 for the control group. As with the experimental group, the control group reached the statistical difference between pre-test and post-test (t = −3,836, p = 0.00) (Table 5).

Table 5.

Comparison of professional competence before and after intervention for experimental and control group.

					n = 120
Variables	Pre-test	Post-test	Mean difference<	T	p
Experimental
PC overall	70.95 ± 9.38	82.55 ± 8.54	11.6	−8.716	.000
Control
PC overall	76.46 ± 7.70	81.37 ± 8.94	4.91	−3.836	.000

Paired t-test, Significant at p < 0.05.

Table 6 compares the mean scores of the pre-test, six-weeks and post-test at twelve weeks of the experimental and control groups in overall professional competence and the six competences areas. It also compares the pre-test scores between experimental and control group examined by independent t-test. The total scores of the pre-test PC overall between the experimental and control groups reached statistical significance (t = 3.511, p = 0.001; Table 6). The PC scores of the participants in the SPRINT group improved significantly after 12 weeks of the educational intervention. The pre-test mean scores of overall professional competence and the six competence area have significant differences (p < 0.05) between the two groups. By following the SPRINT program, the experimental group was statistically higher than the control group for overall PC and the six competence areas in the post-test at six weeks and the post-test at twelve weeks. Value-based nursing care achieved the highest score for the two groups. However, for the control group, it decreased in the six-week post-test and the twelve-week post-test. Furthermore, the DLONC achieved the lowest score for both groups.

Table 6.

Professional competence mean scores and six competence areas of pre-test, post-test 6 weeks and post-test 12 weeks of the experimental and control group (n = 120).

Scale		Experimental (n = 60)	Control (n = 60)	Test value	p value
		Mean ± SD	Mean ± SD
Professsional competence overall	Pre-test Post-test 6 weeks Post-test 12 weeks Test value p value< Bonferroni post-hoc analysisc	70.95 ± 9.38 75.48 ± 8.58 82.55 ± 8.54 26.220 0.001 A (p = 0.017) B (p = 0.017) C (p < 0.001)	76.46 ± 7.70 81.48 ± 8.17 81.37 ± 8.94 7.193 0.001 A (p = 0.003) B (p = 0.003) C (p = 0.004)	3.511 −3.927 0.740	0.001a 0.000 0.461
Nursing care	Pre-test Post-test 6 weeks	73.16 ± 10.53 74.66 ± 10.40	76.41 ± 10.25 79.50 ± 8.71	−1.712 −2.757	0.089a 0.007a
	Post-test 12 weeks	81.91 ± 10.97	81.50 ± 10.86	0.209	0.835a
	Test value	11.600b	3.945b
	p value	0.000b	0.021b
	Bonferroni post-hoc analysisc	A (p = 1.000)	A (p = 0.278)
		B (p = 1.000) C (p < 0.001)	B (p = 0.278) C (p = 0.018)
Value-based	Pre-test	74.91 ± 10.18	79.83 ± 9.06	−2.793	0.006
Nursing Care	Post-test 6 weeks	80.25 ± 9.08	85.16 ± 10.33	−2.768	0.007
(VBNC)	Post-test 12 weeks	86.00 ± 9.51	83.50 ± 10.74	1.349	0.180
	Test value	19.974	4.402
	p value	0.000	0.014
	Bonferroni post-hoc analysisc	A (p = 0.009)	A (p = 0.013)
		B (p = 0.009) C (p < 0.001)	B (p = 0.013) C (p = 0.143)
Medical and	Pre-test	67.41 ± 11.36	75.41 ± 9.12	−4.251	0.000
Technical	Post-test 6 weeks	75.00 ± 10.18	81.66 ± 9.68	−3.522	0.001
Care (MTC)	Post-test 12 weeks	82.83 ± 10.75	79.08 ± 9.76	2.000	0.048
	Test value	34.125	5.010
	p value	0.000	0.008
	Bonferroni post-hoc analysisc	A (p < 0.001)	A (p = 0.007)
		B (p < 0.001)	B (p = 0.007)
		C (p < 0.001)	C (p = 0.112)
Care	Pre-test	71.50 ± 12.53	75.33 ± 10.45	−1.820	0.071
Pedagogic (CP)	Post-test 6 weeks	77.50 ± 10.18	81.66 ± 9.68	−2.296	0.023
	Post-test 12 weeks	82.83 ± 9.44	81.83 ± 10.73	0.542	0.589
	Test value	16.527	7.767
	p value	0.000	0.001
	Bonferroni post-hoc analysisc	A (p = 0.008)	A (p = 0.003)
		B (p = 0.008)	B (p = 0.003)
		C (p < 0.001)	C (p = 0.002)
Documentation	Pre-test	71.56 ± 9.63	76.98 ± 9.31	−3.130	0.002
Administration	Post-test 6 weeks	75.05 ± 9.64	81.66 ± 10.68	−3.562	0.001
Nursing Care	Post-test 12 weeks	82.50 ± 9.14	81.61 ± 10.55	0.491	0.624
(DANC)	Test value	20.867	4.179
	p value	0.000	0.017
	Bonferroni post-hoc analysisc	A (p = 0.136)	A (p = 0.038)
		B (p = 0.136)	B (p = 0.038)
		C (p < 0.001)	C (p = 0.041)
Development	Pre-test	67.18 ± 11.54	74.80 ± 9.41	−3.954	0.000
Leadership	Post-test 6 weeks	70.41 ± 11.78	80.10 ± 10.95	−4.666	0.000
Organization	Post-test 12 weeks	79.27 ± 11.00	80.73 ± 10.50	−0.743	0.459
Nursing Care	Test value	17.915	6.010
(DLONC)	p value	0.000	0.003
	Bonferroni post-hoc analysisc	A (p = 0.373)	A (p = 0.016)
		B (p = 0.373) C (p < 0.001)	B (p = 0.016) C (p = 0.006)

Notes: A:pretest versus posttest 6 week; B: posttest 6 weeks versus posttest 12 weeks; C: posttest 12 weeks versus pretest . ^aIndependent t-test; ^b Repeated Measures ANOVA (Analysis of Variance). ^cSignificant at p < 0.05.

When the mean scores were compared in three-time occassions, the overall PC and the six competence areas (NC, VBNC, MTC, CP, DANC, DLONC) significantly increased (p < 0.05) for the experimental group. Based on the ANOVA test with the Bonferroni post hoc analysis, there was a difference between the PC overall score average in the pre-test and the post-test at six weeks, the post-test at six weeks with the pre-test, and the post-test at twelve weeks with the pre-tests. In the experimental group, overall PC and the six competence areas had a significant difference (p < 0.00) in the mean score of the post-test at twelve weeks with the pre-test. The MTC had a significant difference in three Bonferroni post hoc analyses (p < 0.00). When the control group tests were evaluated, there was no difference in the six competence areas except the overall PC. However, in this group, the scores slightly decreased in overall PC, VBNC, MTC, CP, and DANC from the six-week post-test to the twelve-week post-test.

The effect of SPRINT on professional competence for Indonesian nursing students was assessed using repeated measures ANOVA. Table 7 illustrates the RM ANOVA results for professional competence before and after the intervention for the experimental and control groups. The main effect of testing time (pre-test and post-test measurement) on professional competence mean score changes was statistically significant, (F2, 118) = 8.155, p = 0.000, partial eta squared = 0.228. The influence of time amounted to 22.8% of overall professional competence variability. There was also a significant interaction effect of time with the group on professional competence, (F2,118) = 34.800, p = 0.000, partial eta squared = 0.065. The interaction between time and group accounts for 6.5% of total professional competence variability.

Table 7.

Summarized Result of the Repeated Measures ANOVA for professional competence.

Source	Sum of Squares	df	Mean Square	F	Sig.	Partial eta squared
Time	4124.902	2	2062.451	34.800	0.000	.228
Group	1.067	1	1.067	10.468	0.002	.081
Time × Group	966.667	2	483.334	8.155	0.000	.065
Error (Time)	12.028	118	109.993

5. Discussion

Nursing students are required to carry out effective professional socialization in their transition from theoretical to clinical education and thus become competent nurses. This study developed and implemented a SPRINT program based on a theory, concept, and guidelines of professional socialization in nursing and attempted to assess the effect on professional competence among Indonesian nursing students. This study showed that performance in six competence areas increased significantly in the experimental group after they following SPRINT program for 12 weeks, while the control group increased only slightly. The control group had the higher score of professional competence in pre-test when compared to experimental group. However, the professional competence score improve significantly after post-test 12 weeks for experimental group. In the literature, there is a scarcity of comparable intervention programs that focus on the professional socialization of NS. However, such a socialization program for NGN could support their transition into the profession, significantly improve their sense of belonging, decrease their feelings of dissatisfaction and a desire to abandon their careers, and increase retention rates [30].

These findings were similar to a previous study in Iran [16] that reported socialization helped NS transition from an insider to an outsider position, eventually becoming a competent professional nurse through metamorphosis. Furthermore, several other studies have found that NS had a sense of belonging after being accepted in the nursing profession which enhanced their clinical competency [14,17]. Professional socialization helps students improve their coping skills and resilience to achieve clinical competencies by balancing expectations and experience in reality practice [15,44]. It is also supported by a professional socialization review describing increased competency in hard skills and soft skills [8] and developing professionalism [20,26]. In relation to that, the present study found that the six competency areas of NS increased significantly after the SPRINT program. At the end of the program, they had a higher level of professional competence than pre-clinical education. In general, the researchers executed the SPRINT program well, closely cooperating with NS, nurse educators and clinical preceptors. The availability of the SPRINT module as program guidance and including learning activities for twelve weeks enhances NS's active participation in learning, interaction, adaptation and development of professional competence. Furthermore, multiple studies have found that professional socialization can enhance students' self-confidence and soft skills, such as professionalism, collaboration, and communication [8,17]. In this study, NS enhanced professional competence, including hard skills and soft skills, by following the SPRINT intervention.

The Association of Indonesian Nursing Education Center (AINEC) has developed the core curriculum of Indonesian Nursing Education 2015 for bachelor nursing in academic and professional degree. In addition, the ASEAN Nursing Common Core Competencies (NCCC) was adopted for the core curriculum, which included the practice of ethical and legal, the practice of professional nursing, management and leadership, research and education, and the development of professional and quality [45]. The AINEC [46] has stated the core competencies of nursing graduates in the twenty-first century, such as critical thinking skills, problem-solving abilities, effective communication and teamwork, creativity, computer literacy, adaptability, leadership skills, and personal development are all required. Integrating one's knowledge, abilities, and attitude into one's work as a health professional is defined as professional competence [46]. Professional competence is the main objective of nursing education globally to ensure patient safety and quality of nursing care [[12], [37], [47], [48]]. A study found that the Indonesian version of the nurse professional competence (NPC) found a valid and reliable tool to measure professional competence among nursing students. It consists of six competence, both hard skills and soft skills as well as suits the core competencies in Indonesian nursing education, such as nursing care, value-based nursing care, medical and technical care, care pedagogics, documentation and administration nursing care, and development of leadership organization nursing care [49].

The present study also revealed that the value-based nursing care had the highest competence of the two groups in the pre-test, the six-week post-test and the twelve-week post-test after the SPRINT program. In post-tests, the experimental group had increased significantly following the SPRINT program, while the control group had decreased slightly. Both SPRINT and conventional socialization offered and encouraged students to exercise these competence areas when they were exposed to similar conditions in clinical settings. In this study, however, the SPRINT program encouraged students’ active learning and interaction with clinical preceptors, nurses, peers, and other health professionals to improve their competence. The students also appeared to develop their ability to utilize the knowledge and experience of their patients. They performed assertive communication, showed integrity, ensured patient dignity, showed openness and respect for different values and beliefs. Moreover, they also adapted their nursing roles to provide nursing care independently and holistic view through team collaboration. Similarly, multiple studies have found that value-based nursing care is considered to be the highest competence area [[4], [47], [50]]

Another aspect of the present study showed that DLONC was the lowest in the pre-test for both groups. Similarly, a previous study in Sweden [50] and a recent study in Australia [4] revealed that DLONC was the lowest competence area among NS. If this is the case, participating in a professional program in clinical education could enable students to achieve a higher level of professional competence and could show significant differences in the mean score of the three tests in both groups. In reality, however, it seems like it would be difficult to improve this competence since the students have little opportunity to learn and practice tasks such as competence in leadership, making decisions, developing nursing care, applying emergency medical principles, implementing evidence-based practice and collaborating interprofessionally. Swedish student nurses at graduation had the lowest mean score in organization and development of nursing care due to the fact that this area of competence was complex. It is impossible to fully develop this competence during the undergraduate nursing education [47]. However, SPRINT has the ability to develop these competence areas to a certain extent. In the present study, students were actively engaged in a learning process whereby they performed a blue code in an emergency situation in which they had to interact and collaborate with other professionals. It also enabled them to develop their competency of taking action to provide nursing care and implement evidence-based practice in their nursing care plan. Thus, they could adapt to new roles of professional nurses by following the SPRINT program in clinical education.

In the present study, the SPRINT program composed multiple learning methods and activities to enhance competency and students’ readiness. Self-directed learning is an effective educational strategy to strengthen competence, self-confidence and readiness during workplace experience [51]. Self-directed learning is proven as an effective pedagogical method for instilling and improving professional values for NS [52]. In relation to this, reflective practice can develop self-directed learning, improve decision-making, help to apply theory into practice and encourage NS to act professionally [53]. Self-learning is one of the most effective learning methods that promotes professional socialization for nursing students [54]. Furthermore, peer learning improves cognitive skills, self-confidence, autonomy, critical thinking, clinical reasoning, collaborative skills, and leadership [55]. Experiential learning offers an excellent chance for professional socialization and enhances students’ coping skills [56], promotes personal resilience [57] and meets work-life needs for nursing students [42]. Moreover, the SPRINT program provides learning, interaction, development and adaptation to new roles. The professional socialization process creates a sense of belonging in the nursing profession, forms a professional identity [17] and fosters professionalism, leading NS to become competent nurses [8]. In this present study, the SPRINT intervention enhanced students’ competencies hard skills and soft skills.

This study has several strengths such as its use of a quasi-experimental study with non-equivalent control group pre-test post-test design. Furthermore, it has a novel type of intervention namely SPRINT program as well as its utilization of a valid instrument. Admittedly, it still has several limitations. For example, the sample for this study was recruited using convenience sampling from two private universities, which limits its generalizability. The participants in both the experimental and control group had their outcomes measured twelve weeks after completing the clinical practice. This might not accurately reflect the long-term effects and so, again, this may limit the generalization of the results. Furthermore, the participants practiced in different teaching hospitals in Indonesia and so had different organizational cultures. Thus, the researchers recommend that such studies should be concentrated on just a few teaching hospitals when conducting related studies in the future.

6. Conclusion

The current study revealed that SPRINT as an innovative professional socialization program had an effect on enhancing professional competence among undergraduate nursing students. It is one way to facilitate a smooth transition of NS from the academic phase to clinical education. The SPRINT activities use varied learning strategies which positively impact students' resilience and independence, enhancing their competency in both hard skills and soft skills. Moreover, since these activities are carried out before, during ad after clinical practice, they can also shape the student nurse's professional identity and improve the sense of belonging in the nursing profession. It is suggested that the undergraduate nursing program considers implementing SPRINT to assist students' transition both academic and professional education. The implementation of SPRINT interventions in other universities and clinical settings will allow for more generalizability. More research on the long-term effects of the SPRINT program is required.

Declarations

Author contribution statement

Wulan Noviani: Conceived and designed the experiments; Performed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper. Mei-Chan Chong, PhD; Li-Yoong Tang: Conceived and designed the experiments; Wrote the paper.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability statement

The data that has been used is confidential.

Declaration of interest's statement

The authors declare no competing interests.

Appendix A. Supplementary data

The following is the Supplementary data to this article: